FORM

Last updated: June 29th, 2020 at 07:41 pm

REQUIRED FORM-Health & Safety

PRE-TREATMENT-SCREENING CHECK (COVID-19)  Pre-screening is now a public health recommendation for patients prior to attending for treatment. This measure is an effort to minimise the risk of the spread of COVID-19 within our communities. Pre-screening should be completed prior to a patient attending the clinic as a risk management protocol.

COVID-19: In compliance with Health & Safety Guidelines, it is clinic policy that precautionary measures are taken to prevent “close contact” during your visit with us.

“Close contact” as defined by the HSE is: “any individual who has had greater than 15 minutes face to face within 2 metres contact in any setting”. We avoid this by doing the following:

The acupuncturist wears PPE (face mask & gloves). The distance of 2 metres is maintained at all times during your visit (except when inserting/removing needles, which is a combined total of less than 15 minutes).

Name
Date
Contact Number
PRE-TREATMENT-SCREENING QUESTIONS: circle Yes or No

 

YES NO
Have you been diagnosed with confirmed or suspected  COVID-19 infection in the last 14 days?
YES
NO
Have you been in close contact with a confirmed or suspected case of COVID-19 in the last 14 days?  (i.e. less than 2m for more than 15mins accumulative in 1 day).
YES
NO
Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days?
YES
NO
Have you been advised by a Doctor or the HSE to self-isolate at this time?

 

YES
NO
Have you been advised by a Doctor or the HSE to cocoon at this time?

 

YES
NO
Have you travelled outside the country in the last 14 days
YES
NO

I understand that this information is required for the purposes of public health & will be kept on file for a 2 month period from the date of signing. I confirm that the above information is true & accurate from the date of signing. I understand that my personal information including my name & contact details may be shared with the Health Service Executive(HSE) for the sole purpose of contact tracing in line with public health guidelines only if requested.

I verify that the acupuncturist is/was wearing PPE (face mask & gloves) & the precautions to prevent “close contact” listed on above are in place & adhered to.

Signature ____________________________________     Date: ___/___/_____